Treatment algorithms for divertculitis „Intestinal disorders“ Budapest, May 2.-3. 2008 Wolfgang Kruis Ev Krankenhaus Kalk Universität zu Köln Germany Diverticular disease - pretreatment considerations - ? Acute diverticulitis: .. Severity ? uncomplicated complicated? ? Recurrent diverticulitis: . Structural dammages ? . . Secondary prevention of acute attacks Surgery Diverticular disease - pretreatment considerations - ? Acute diverticulitis: .. Severity ? uncomplicated complicated? Severity and different phases of Diverticulitis mod. acc. to Hansen & Stock, 1999 Phase I Phase II a b c Moderate Severe Mild Mild inflammation Phase III Peridiverticulitis Penetrating Perforatin - Phlegmone - Abscess - - Peritonitis - Acute Uncomplicated Recurrent Complicated Diverticula of the Colon 5 %* 30 % 70 % Asymptomatic Uncomplicated Diverticular disease Complications 100% = All subjects with colonic diverticula •30%: Any Diverticular disease • * 5% of all subjects with diverticula Dis Colon Rectum 1989; 32 Dis Colon Rectum 1996; 39 Clinical Gastroenterology 1975; 4 Diverticulosis - Diverticulitis Divertculitis occurs primarily on the outer side of the bowel wall Ergo: Diagnosis of diverticulitis is made by cross sectional imaging! Diverticulum without surrounding inflammation Ultrasound Diverticulum with surrounding inflammation CT: Diverticulitis with abscess formation Treatment of acute Diverticulitis with complications Perforation Phlegmone / Abscess formation Not self limited bleeding Intervention / Surgery Treatment of acute Diverticulitis - uncomplicated mild - Treatment of acute Diverticulitis - uncomplicated mild Outpatient care possible, Dietary restriction, sufficient fluid replacment, Analgesics (spasmolytics) Drugs: Antibiotics ?? Aminsosalicylates ? Antibiotics for uncomplicated Diverticulitis Retrospective study n = 311; Patients with diverticulitis, treated .. with antibiotics (n = 193) without antibiotics (n = 311) CONCLUSIONS: “Our results indicate that antibiotics are not mandatory in mild acute diverticulitis. Treatment without antibiotics appears to be safe and seems not to change the rate of further events.” Scand J Gastroenterol 2007;42:41-7 Hjern F, Josephson T, Altman D, Holmström B, Mellgren A, Pollack J, Johansson C. Division of Surgery, Karolinska Institutet, Stockholm Mesalamine in painful Diverticular Disease (Diverticulitis) Prospective, randomised (n=123), placebo-controlled; mesalamine pellets 3x1g/d Mesalamine Δ pain score (day 28) 45 40 35 days until relief of pain 25 * 30 25 20 15 10 5 0 ITT PP * Significant difference Placebo % Patients without pain 90 80 * 70 20 60 15 * 10 50 40 30 20 5 10 0 0 ITT PP ITT PP W Kruis et al, DDW 2007 Treatment of acute Diverticulitis - uncomplicated moderate to severe In most patients hospitalisation is recommended, nothing by mouth, i.v. - therapy Analgesics (spasmolytics), fluid/electrolyte substitution Drugs: Antibiotics (If necessary interdisciplinary discussion with surgeons) Diverticular disease - pretreatment considerations - Recurrent diverticulitis: . . . Structural dammages ? Secondary prevention of acute attacks Surgery Treatment of Diverticulitis - recurrent Patients` status: .. . Structural dammages ? chronic abscess formation stenosis fistulae As diagnosed by ultrasound and/or CT and/or colonoscopy (stenosis) Risk factors for development of complicated Diverticulitis Immunoincompetence JD Perkins et al. Am J Surg, 1984 ES Tyau et al. Arch Surg, 1991 Drugs (NSAIDs) AR Hart et al. Eur J Gastroenterol Hepatol, 2000 Diabetes mellitus S Hollerbach, 2006 Phenotype: young, fat, male JA Acosta et al. Am Surg, 1992 J Freischlag et al. Dis Colon Rectum, 1986 PR Schauer et al. Am Jsurg, 1992 Localisation (right-sided) Y Reismann et al. Int J Colorectal Dis, 1999 Treatment of Diverticulitis . - recurrent Structural dammages and / or . Risk factors Consider elective surgery Treatment of Diverticulitis . - recurrent Without structural dammages and / or . Risk factors Treatment of recurrent Diverticulitis - prevention of acute attacks Secondary prevention of acute attacks - physical activity - fibre (Plantago) Drugs: Cyclical antibiotics Aminosalicylates (?) Probiotics ?? Elective surgery (?) Prevention of divertikulitis - diets and life style - Prevention of acute attacks of recurrent diverticulitis with cyclical Rifaximin Global symptom score C Papi et al Aliment Pharmacol Ther 1995; 9:33-39 Prevention of acute attacks of recurrent diverticulitis with Antibiotics +/- Mesalazine Patients free of symptoms (%) 90 80 *** Rif+Mes Rif *** *** 70 60 50 *** 40 30 20 10 0 3 6 9 n = 218; recurrent divertikulitis Group combined Rif + Mes: Rifaximin 400 mg bid + 7 days Mesalazine 800 mg bid Afterwards Rifaximin 400 mg bid 1 week/ + month Mesalazine 800 mg bid Group Rifaximin: Rifaximin 400 mg bid 7 days Afterwards 1 week/ Rifaximin 400 mg bid month 12 Months A Tursi et al Digest Liver Dis 2002; 34:510-515 Recurrent Diverticulitis: Remission after Mesalazine Probability to remain in remission 1 Mesalazin Kontrolle 0,9 0,8 0,7 0,6 n = 166 Drop outs n = 44 (12 bec/ complications 7,2% ) p < blinded ?? 0,001 randomisied ?? 0,5 0,4 0,3 E Trespi et al Minerva Gastroenterol Dietol 1999; 45:245-252 0,2 0,1 0 12 24 36 Mesalazine 2x400mg/d 7 days 8 Weeks O-diet + antibiotics controls > 30g fibres/d 48 months 48 months follow-up Uncomplicated recurrent Diverticulitis - elective surgery – consensus statement The number of attacks of uncomplicated diverticulitis is not necessarily an overriding factor in defining the appropriatness of surgery. CT graded severity of a first attack is a predictor of an adverse natural history and may be helpful in determing the need for surgery. The Standards Committee of The American Society of Colon and rectal Surgeons Dis Colon Rectum 2006;49:939-944 Treatment algorithms for divertculitis - Summary Surgery Diet 0-Diet iv-therapy/substitut Analgesics Analgesics 5-ASA Antibiotics Mild Complicated Surgery Fibre Phys activity Cyclical antibiotics 5-ASA Probiotics Moderate/Severe Uncomplicated Acute - With Without structural dammage/ risk factors Recurrent Diverticular disease/Diverticulitis
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